H & a Family Care Home

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for three of three personnel records reviewed. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population. Findings Include: 1. A.R.S. § 36-411 states: C. Each residential care institution, nursing care institution, and home health agency shall make documented, good-faith efforts to: 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee. 5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant to section 46-459." 2. A review of E1's personnel record (hired on April 25, 2016) did not include documentation of the verification that E1 was not on the adult protective services registry. 3. A review of E2's personnel record (hired on November 1, 2025) did not include documentation of the verification that E2 was not on the adult protective services registry. 4. A review of E3's personnel record (hired on January 1, 2026) did not include documentation of the verification that E3 was not on the adult protective services registry. 5. In an exit interview, the findings were reviewed with E1 and E4 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113, for two of three personnel sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of E2's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if E2 had signs or symptoms of TB. Based on E2's hire date, this documentation was required. 3. A review of E3's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if E3 had signs or symptoms of TB. Based on E3's hire date, this documentation was required. 4. In an exit interview, the findings were reviewed with E1 and E4 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of two residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of R1's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R1 had signs or symptoms of TB. Based on R1's date of acceptance, this documentation was required. 3. A review of R2's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R2 had signs or symptoms of TB. Based on R2's date of acceptance, this documentation was required. 4. In an exit interview, the findings were reviewed with E1 and E4 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided in the resident's medical record, for one of two residents sampled. The deficient practice posed a risk as the Department was provided false and misleading documentation as the facility pre-filled activities of daily living documentation. Findings include: 1. A review of R2's medical record revealed a document titled "Activities of Daily Living," which documented the services that were provided to R2 in January 2026. Further review of the documentation revealed all services on January 30, 2026 (the day of the inspection) had been prefilled with initials to indicate all services had been provided for the day. 2. In an exit interview, the findings were reviewed with E1 and E4, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that the service plan for a resident receiving directed care services included documentation of the resident’s weight or documentation from a medical practitioner indicating that weighing the resident was contraindicated, for one of two residents sampled. Findings include: 1. A review of R1’s medical record revealed a service plan update dated January 15, 2026, and indicated R1 received directed care services. However, R1’s service plan did not include R1’s weight or documentation from R1’s medical practitioner stating that weighing R1 was contraindicated. 2. In an exit interview, the findings were reviewed with E1 and E4, and no additional information was provided. This is a repeat deficiency from the on-site inspection completed on October 5, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure that when medication was stored by an assisted living facility, policies and procedures were implemented for discarding medication for one of two medical records reviewed, which posed a health and safety risk to a resident. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Disposal of Medications." The policy stated "...All expired and discontinued medications...as follows: The medication will be offered to the resident's family first...In the event no one wants the medication it will be disposed of by the facility dissolving the medication in warm water, hydrogen peroxide or vinegar in a disposable container of zip lock bags, the dissolved medication will be poured to an old newspaper...then be placed in the trash receptable...All medication disposal will be documented on the Medication Disposal Form and signed and dated by the parties involved..." 2. A review of R1's medical record contained a document titled "Doctor's Orders" dated August 1, 2025, which included the following medication order: -Citalopram; 20 mg; by mouth..." 3. The Compliance Officer observed a Citalpram 20mg medication bottle in R1's medicine bin, which stated "Take 1 Tablet Once Daily." Further review of the medication label attached to the bottle revealed the medication had expired on August 15, 2025. 4. In an interview, E1 and E4 acknowledged the medication had expired. 5. In an exit interview, the findings were reviewed with E1 and E4 and no additional information was provided. This is a repeat deficiency from the inspection conducted on October 5, 2023.

Based on observation and interview, the manager failed to ensure the required smoke detectors were tested at least once a month and documented, which posted a safety risk. Findings include: 1. During the review of the facility's documentation the compliance officer requested and was provided with the monthly documentation of the testing of the required smoke detectors for the past 12 months. The documentation did not include May, August, and September of 2023 to indicate the testing of the smoke detectors. 2. In an interview, E4 acknowledged there was no documented evidence the smoke detectors were tested monthly as required.

Based on documentation review and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery which posed a health and safety risk to the residents, for five of five sampled personnel records reviewed. Findings include: 1. Review of the facility's documents revealed no documented evidence the fall prevention and fall recovery training program had been implemented for all employees. 2. Reviewed of five employee records found there was no documentation that E1, E2, E3, E4, and E5 had completed the required training. 3. In an interview, E1 and E4 acknowledged the facility did not have documentation that all the employees had completed the required annual fall prevention and fall recovery training. This is a repeat deficiency from the complaint investigation conducted on November 22, 2022.

Based on record review and interview, the manager failed to ensure an assistant caregiver interacted with a resident under the supervision of a manager or caregiver, for one of one assistant caregiver. The deficient practice posed a risk as the individual was not qualified to provide the required services. Findings include: 1. Review of A.R.S. \'a7 36-401.A.42. revealed "Supervision" means direct overseeing and inspection of the act of accomplishing a function or activity. 2. Review of E3's personnel record, who was hired May 26, 2023, revealed no documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers. In addition, E3's record did not include documentation showing an administrator's license, a nursing license, or employment as a caregiver prior to November 1, 1998. Therefore, E3 was not qualified to be left alone with a resident based on the lack of caregiver training. E3's record contained job duties for an assistant caregiver. 4. In an interview, R4 reported how (E3) helped R4 with hands-on bathing and getting in and out of the shower. R4 reported there was no one else present during R4's shower. E4 after hearing R4 reporting this information informed E3 that E3 was not allowed to give a resident a shower unless E2 was with E3. 5. In an interview, E3 reported that E3 was an assistant caregiver. 6. In an interview, E1 and E4 acknowledged that E3 was an assistant caregiver providing direct care to residents without direct supervision as required.

Based on documentation review, record review, and interview, the manager failed to ensure an assistant caregiver's skills and knowledge were verified and documented before providing physical health services and according to policies and procedures; for two of two sampled assistant caregivers' personnel records reviewed, which posed a health and safety risk. Findings include: 1. Review of the personnel records revealed E3 started on May 26, 2023 and E5 started on April 9, 2023. E3's and E5's records contained no documentation that these two sampled assistant caregivers' skills and knowledge were verified to provide the services they were expected to provide according to the facility's scope of services. 2. In an interview, E1 and E4 acknowledged there was no documentation available showing that E3's and E5's skills and knowledge had been verified and documented as required. This is a repeat deficiency from the complaint investigation conducted on November 22, 2022.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials that were stored by the facility were stored in a locked area and inaccessible to residents. Findings include: 1. During a facility tour, E4 and the compliance officer observed in R1's bathroom the facility was storing unlocked toilet bowl cleaner that was sitting on the floor next to R1's toilet. Record review indicated the resident was receiving directed care services. 2. In an interview, E4 acknowledged the unlocked poisonous or toxic materials were being stored by the facility and were accessible to R1.

Based on record review and interview, the manager failed to ensure two of three sampled residents had a residency agreement that included whether the manager or a caregiver was awake during nighttime hours which posed a health and safety risk. Findings included: 1. Review of R1's and R2's residency agreement revealed that there was no documentation of whether the manager or a caregiver was awake during nighttime hours. Based on the residents' dates of acceptance this documentation was required. 2. In an interview, E1 and E4 acknowledged the R1's and R2's residency agreement did not contain notification to the resident or representative whether the manager or a caregiver was awake during nighttime hours.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by the assisted living facility, there was a documented residency agreement with the assisted living facility which included the manager's signature and date; for one of three sampled residents' agreements reviewed. Findings include: 1. Review of R2's record revealed a documented residency agreement. The residency agreement was not signed and dated by the manager. Based on the resident's date of acceptance this was required. There was no documentation that the manager had delegated, in writing, a person to sign on the manager's behalf, as required in A.A.C. R9-10-803.F.3. 2. In an interview, E1 and E4 acknowledged the manager did not sign and date R2's residency agreement before or at the time this resident was accepted to the facility nor anytime since. E1 acknowledged the manager had not put in writing who the manager had delegated to sign this residency agreement on behalf of the manager on or prior to the date of acceptance.

Based on record review and interview, the manager failed to ensure that a documented residency agreement included the signature and date of the resident, the resident's representative, the resident's legal guardian, or another individual designated to make health care decisions, for one of three residents reviewed. Findings include: 1. Review of R2's record revealed a residency agreement. Based on the date of acceptance, this residency agreement did not include the signature and date of the resident, the resident's representative, the resident's legal guardian, or another individual designated to make health care decisions. This residency agreement was required to be signed based on the resident's date of acceptance. 2. During an interview, E1 and E4 acknowledged R2's residency agreement did not include a signature and date of the resident, the resident's representative, the resident's legal guardian, or another individual designated to make health care decisions, as required.

Based on record review and interview, the manager failed to ensure that two of four residents' medical records, who were receiving directed care services, included documentation of the resident's weight on the service plan or documentation from a medical practitioner stating that weighing the resident was contraindicated. Findings include: 1. Review of R3's current service plan, dated July 7, 2023, and R4's current service plan, dated July 15, 2023, stated the residents required directed care services. Neither the service plans nor their medical records contained any documentation of the residents' weight when the service plans were updated. There was no documentation in R3's and R4's medical records from the residents' medical practitioners stating that weighing the resident was contraindicated. 2. During an interview, E1 and E4 acknowledged R3's and R4's weight were not documented as required. E1 and E4 acknowledged there was no documentation from their medical practitioner stating that weighing the resident was contraindicated. No other medical documentation reflecting the resident's current weight was available for review.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked room, closet, cabinet, or self-contained unit; which posed a health and safety risk. Findings include: 1. During a facility tour, E1 and the compliance officer observed in the facility's reach-in unlocked refrigerator door there was stored unlocked four boxes of Calcitonin Salmon Nasal Spray for R4, one bottle of Pepto Bismol with no one's name on the bottle. and five acetaminophen suppositories 650 mg for R5. The acetaminophen had expired March 6, 2023. 2. In an interview, E1 and E4 acknowledged the medications were not stored in a locked cabinet which posted a health and safety risk. E1 reported R5 was discharged. This is a repeat deficiency from the complaint investigation conducted on November 22, 2022.

Based on record review and interview, the manager failed to dispose of a discontinued medication including an expired medication according to the facility's policy and procedure, which posed a health and safety risk to a resident. Findings include: 1. During a facility tour, E1 and the compliance officer observed in the facility's reach-in unlocked refrigerator door there was stored five acetaminophen suppositories 650 mg for R5. The acetaminophen had expired March 6, 2023. 2. In an interview, E1 and E4 acknowledged the expired medication. E1 reported R5 had been discharged. 3. The facility's established and documented policy and procedure for "Discarding/Disposal" stated: "1. offer back to pharmacy or family... 2. make sure a written and signature with witness form will be filled out immediately the time of medications pick up. 3. A policy and procedure of Medication Disposal Record that contains: a. Resident name, b. Medication name and strength, c. Quantity destroyed, d. Reason for disposal, e. Disposed by..., f. date destroyed" 4. In an interview, E1 and E4 acknowledged the facility did not implement their policy and procedure of discarding and disposing of a medication including an expired medication.